Abstract: PUB060
Two Cases of Postpartum Thrombotic Microangiopathy (TMA) Associated With Renal Cortical Necrosis (RCN) Treated With Eculizumab
Session Information
Category: Acute Kidney Injury
- 102 AKI: Clinical‚ Outcomes‚ and Trials
Authors
- Katz, Nurit S., Massachusetts General Hospital, Boston, Massachusetts, United States
- Yatim, Karim, Massachusetts General Hospital, Boston, Massachusetts, United States
- Heher, Yael Kushner, Massachusetts General Hospital, Boston, Massachusetts, United States
- Zonozi, Reza, Massachusetts General Hospital, Boston, Massachusetts, United States
- Niles, John, Massachusetts General Hospital, Boston, Massachusetts, United States
- Jeyabalan, Anushya, Massachusetts General Hospital, Boston, Massachusetts, United States
Introduction
Postpartum TMA is a rare potential cause of RCN, often with hemorrhage preceding acute kidney injury (AKI). The utility of complement blockade in this setting is unknown. We describe 2 patients who achieved renal recovery post eculizumab therapy.
Case Description
Case 1: A 35 y.o woman with history of HTN was admitted for premature rupture of membranes and chorioamnionitis at 31 weeks gestation requiring Caesarean section, complicated by hemorrhagic shock and E. Coli bacteremia. She developed abrupt anuric AKI requiring HD, concurrent microangiopathic hemolytic anemia (MAHA) and low C3 levels. Kidney biopsy revealed severe TMA with RCN (Figure 1). Eculizumab therapy resuled in rapid hematological improvement. After 8 doses of eculizumab, 3 months postpartum, her kidney function improved and both HD and eculizumab therapy was stopped (Table 1). Complement panel was negative.
Case 2: A 37 y.o woman presented after spontaneous septic abortion at 5 weeks gestation requiring dilation and curettage complicated by significant hemorrhage and abrupt anuric AKI requiring HD. Labs revealed concurrent MAHA and disseminated intravascular coagulopathy (DIC). Contrast CT revealed bilateral RCN (Figure 2). Given ongoing MAHA and AKI, renal TMA was clinically diagnosed. After 2 doses of eculizumab, she had rapid hematological improvement and 4 months postpartum, she had adequate renal recovery to stop HD (Table 1). Functional complement panel showed mild complement dysregulation.
Discussion
Postpartum TMA due to alternative complement pathway defects appears to be associated with RCN, a devastating renal complication of pregnancy. Eculizumab, an inhibitor of complement protein C5, may lead to favorable renal outcomes in this population.
Creatinine trends
| baseline Cr | Day of AKI (postpartum day) | Cr on day of dialysis initiation | Cr upon discharge* * On iHD | Cr Most recent* *Off iHD | |
| Case 1 | 0.56 | 1.35 (d4) | 9.84 (d8) | 5.72 | 2.19 |
| Case 2 | 0.65 | 1.65 (d2) | 4.69 (d3) | 9.75 | 2.99 |
Cr: Creatinine d: Day post-partum iHD: Intermittent hemodialysis